Care & Repair Edinburgh

Service request form

Date
Referred by
of
Contact Tel.
Email
Client Details
Mr Mrs Miss Ms Other - Title
Name
Address
Postcode
Tel No
Date of Birth
Ethnic Origin
	If Mixed Race or Other, please give details
Disability
Housing Owner Private Rental RSL (housing association) LA Other
Please tick as appropriate: Hospital discharge
Date	(if known)
Community Alarm Service (CAS) link: already linked link requested
Job description
Specific information
There is a charge of £20.00 for all small repairs and joinery work, plus the cost of materials or equipment supplied such as keysafes. Cheques should be made payable to Care and Repair Edinburgh and sent to 4 Queen Street, Edinburgh EH2 1JE. (Please write keysafe on back and address where keysafe is to be fitted). If keysafe is to be removed, please state the access code number.
Any personal information that you supply will be held in accordance with the requirements of the Data Protection Act 1998. The information we keep will be used for: The purpose of dealing with your enquiry Sending you information that you have requested Evaluating the service we have delivered to you Researching other services we might develop